SELECTED STUDIES
RECONSTRUCTION
OF THE ESOPHAGUS
IN LESS THAN ONE YEAR OLD INFANTS
By Prof. José Miguel Alvear,
MD, FICS
Summary:
Esophageal reconstruction in infants is a much more delicate and difficult surgical procedure than in adults. The results on the other hand can be lifesaving or catastrophic. There may be several reasons for reconstructing the esophagus. One of them is the atresia or congenital absence of the esophagus. A case of total esophageal atresia is used for this lecture where the long term results are demonstrated.
We advocate early esophageal reconstruction with left colon in infants one year old or less mainly because of multiple complications they go through if they have to wait years fighting high morbidity, until they are “accepted” for final surgical procedure. The quality of life for these infants and their parents is a lot better than with other surgical techniques. Also in our patients (few followed up for 20 years), no one has developed peptic colitis of the interposed colon. This of course is related to the surgical technique used for the colo-gastric anastomosis.
The gastro-colonic anastomosis should be performed in a sphinteric fashion – Alvears’ fashion is one style – in order to make sure no reflux of gastric contents occurs into the interposed segment of colon.
Introduction:
The atresia coexists most of the time with a fistula between esophagus and trachea.
As Gross classification the frequency is a follows:
The incidence of atresia is approximately once every four thousand births, 60%
among males, 40% among females.
Diagnosis:
The case for this presentation is a one day old newborn with excessive salivation, respiratory difficulty, head and neck cyanosis. The esophagogram using an indwelling nasoesophageal catheter show the total esophageal atresia without fistula and the initial surgical procedure was carried out: cervical esophagostomy and feeding gastrostomy
First Surgical Procedure: Cervical Esophagostomy and Feeding Gastrostomy
The cervical esophagostomy is done through an oblique incision parallel to the left esternocleidomastoid muscle preserving very carefully the nerves of the brachial plexus, the digestive nerves as well as the suprarclavicular veins and arteries. For the gastrostomy it is important to consider that babies with esophageal atresia without fistula do not develop the stomach, this is atrophic, therefore the entire anterior wall of the small stomach must be used for the gastrostomy itself. It is wise to use the gastrostomy tube for x-ray contrast check up of potential intestinal atresias that may coexist during the immediate postoperative period. The feedings using the gastrostomy tube are started and much care should be provided due to the abundant regurgitation and nutritional consequences.
Final surgical procedure: Esophageal reconstruction
We advocate early
esophageal reconstruction using the splenic flexure of the colon for infants one
year old or less mainly because of multiple complications and high morbidity
these patients go through while they wait to be accepted for final surgical
procedures. The quality of life for these infants and their parents is a lot
better than with other operations. Also among our patients followed for more
than 12 years, no one has developed peptic colitis of the interposed colon. This
of course is related to the technique used for the colo-gastric anastomosis.
Operative Technique:
The definitive surgery is done as follows: middle line incision from xyphoid to below umbilicus. Stomach and colon mobilization. By transilumination we observe the irrigation of transverse and descending colon. The segment of left colon that is going to be brought to the chest is selected and vascular clamps are placed to completely isolate the vascular supply for this segment. It is left in place for as long as we continue with the following steps of the operation.
Having completed the preparation of the abdominal access to the chest we move on to the neck. By means of similar incision for the neck esophagostomy we mobilize the cervical esophagus and prepare it for anastomosis. Then we carefully make the retro-esternal chest tunnel by extra pleural dissection from neck to xyphoid, manual and blont dissection. Much care should be taken not to enter pleural cavities nor pericardium.
All this time is plenty to ensure adequate vascular supply to the segment of selected left colon. Thereafter we proceed to disconnect the most appropriate length of left colon so prepared to mobilize it to the chest keeping the vascular pedicle untwisted. Once the most appropriate length has been obtained, we pass the colonic segment through the chest tunnel and manually obtain the most anatomical placement.
Then we reconnect the large bowel by end to end colonic anastomosis. Next we continue with the upper anastomosis in the neck, end to side esophago-colonic anastomosis and finally the gastrocolonic anastomosis performed at the upper anterior gastric wall. This is the most important of all anastomosis. Should be carefully made into a functional sphinteric junction between the distal end of the interposed colonsegment and the stomach. Finally we perform appendectomy and pyloroplasty if necessary. After washing the abdominal cavity all the surgical incisions are closed.
Post
Operative Management:
Respiratory functions and control of digestion are most important during the immediate postoperative period. Feeding through the gastrostomy tube starts 24 hours after surgery. Radiographic controls by barium swallow are done 4 to 5 days after surgery at time of patient’s discharge. From then on radiographic controls are done periodically as well as motion video controls from swallow to colonic empting inside the stomach, without reflux.
Conclusions:
Prof. José Miguel Alvear, MD,FICS is the president of the Ecuadorian Academy of Medicine and professor of surgery, Central University of Ecuador. He has a plethora of scientific publications. Email: jmalvear@accessinter.net
